Syncope at the Free Throw Line | Patient Case Quiz

A 16-year-old, competitive, African American male basketball player presents after "failing" the pre-participation 12-point American Heart Association (AHA) screening examination.1 During the course of evaluation, he mentions that he occasionally feels chest pain during high-intensity running drills, occasional "extra beats" at rest, and episodes of suddenly "passing out," without premonitory symptoms, at the free throw line when he raises his arms to shoot. His family history is negative for sudden cardiac death, aneurysms, deafness, seizure, sudden infant death syndrome, pacemaker, implantable cardioverter-defibrillator, or need for cardiac transplant. Physical examination reveals a tall, athletic-appearing male with the following characteristics: resting heart rate in the 50s, blood pressure (BP) of 120/70 mm Hg, normoactive precordium, and non-displaced point of maximal impulse (PMI). He has a normal S1, physiologic S2, and no murmurs, with good and equal peripheral pulses. Of note, there is no high-arched palate and no arachnodactyly.

His electrocardiogram (ECG) is shown in Figure 1.

Figure 1

Figure 1

Selected transthoracic echocardiogram clips are shown in Videos 1 and 2.

Video 1

Video 2

A Holter monitor, obtained due to resting bradycardia and complaints of extra beats and syncope, shows a predominance of sinus rhythm, with rate varying from a low of 37 BPM during sleep (without sinus pauses nor atrioventricular block) to a maximum of 180 BPM during a pick-up game of basketball. At rest, there is a 5 beat run of wide complex tachycardia at 150 BPM.

Due to the competitive nature of this athlete and his symptoms, an exercise stress test is obtained. He runs through Stage 4 of the Bruce protocol, during which he is asymptomatic, achieving 14 METS, with normal heart rate and BP response, and without ST changes or ectopy.

Which of the following statements describes the next best steps in further testing or intervention for this patient?

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